A battle to win a baby

Jothi B*, Sudha R

OPD Incharge, Kauvery Hospital, Hosur, Tamilnadu

Senior Patient Care Assistant OPD, Kauvery Hospital, Hosur, Tamilnadu

 

Background

This is a case study of one of our patients who had infertility and later on, went on to deliver twin babies.

A 29-year-old female presented to OPD on 6/11/20, requesting treatment for infertility. She had a history of polycystic ovary syndrome (PCOS) and never conceived. History includes Intrauterine insemination (IUI) three years ago which had failed. She underwent laparoscopy and was found to have ovarian swelling a year ago. She was not on any medication nor had any allergies. LMP was on 24/10/20. She was on Apcod sachet (a combination of Myo-Inositol, D-Chiro-Inositol, Vitamin D3, and Alpha Lactalbumin). and Tab. Metformin. She was taking a combination of Myo-Inositol, D-Chiro-Inositol, Vitamin D3, and Alpha Lactalbumin. and Tab. Metformin (Apcod sachet).

After two days she had complained of discomfort and urgency in passing urine, but no fever/body pain/tiredness. Biochemistry reports revealed HbA1c – 8.5, Hb – 14.9, TSH – 0.01 milli-international units per liter (decreased), prolactin – 9.3 ng/ml. On USG abdomen both ovaries were mildly enlarged in size and showed multiple peripherally arranged follicles. She was on Tab. Ovaa shield – DS (Acetylcysteine, Astaxanthin and Clomiphene) TDS for 7 days. Tab. Thyroxine 50 mcg was also added.

On day 13th, on the rupturing of follicles, following drugs were added: Tab. Progynova, 2 mg x 5 days, Tab. Hald SR, 300mg x 14 days, and Tab. Folvite, and advised to continue Apcod sachet. Repeat thyroid profile showed T3 – 1.12, T4 – 7.30, TSH – 2.26., all in mIU/ml.

On 30/12/20, 2nd cycle day, ovulation induction-timed intercourse was done. Her Urine Pregnancy Test (UPT) showed negative. LMP was on 28/12/20. Tab. Zolet (Letrozole) 5 mg x 5 days was added and continued Tab. Folvite/APCOD sachet.

On day 1, Tab. Progynova (Estradiol Valerate) 2 mg x 5 days, Tab. Endothik ES (Estradiol and Sildenafil) x 5 days, Inj Hucog (Human Chorionic Gonadotropin) 5000- IV, Tab. Strone (Progesterone) 200 mg x 14 days and Tab. Progenix (L-Carnitine L-Tartrate, Tribulus terrestris extract, Ubidecarenone, Lycopene, and Zinc) – 1 month and asked to review on day 2 of cycle.

On 1/2/21, on her 3rd cycle of day, ovulation induction- timed intercourse Intrauterine insemination (IUI) was done. LMP- 30/1/21, to Cont. APCOD sachet T. Folvite.

On day 14, advised Inj Hucog 10,000, IV, Tab Naeva (Progesterone ) 200 mg – 14 days and asked to review on day 2 of cycle.

On 8/3/21, she presented with 8 days delayed period and her UPT was positive. She was given Inj Hucog 2000, IV, once a week for 3 weeks, Tab. Susten (Progesterone) 400 mg – 15 days and continued Tab Folvite.

On 21/3/21 – she complained of PV spotting and tiredness. USG revealed viable growth of 6-7 weeks, FH+, Yolk sac + Inj. Hucog 2000 – once a week, continued with Tab. Folvite and Tab. Susten and review after 15 days.

On 31/3/21, C/O PV spotting, mild pain, USG confirmed FH + (8 +3 weeks) FM+.

Tab. Duphaston (Dydrogesterone) 10 mg – 2 weeks, Tab. Dubagest (progesterone) SR 200 mg and continued with Folvite.

Inj Hucog 2000 IV once in a week for 4 weeks. On her 10th week, (11/4/21), she was advised to stop Tab. Duphaston and to review with nuchal translucency (NT) scan after 15-20 days.

MRI scan revealed diamniotic and dichorionic intrauterine twin gestational sacs with live embryo within. Ultra sound revealed (18/4/21) two sac noted with one gestational sac measures 1.7 cm and the other gestational sac measures 1.7 cm. Fetal cardiac activity normal in both twin. Mild sub chorionic bleed noted. Right ovary shows a cyst measuring 3.4 cm, a complex mass lesion measuring 4.5 2.2 cm in size with a central sac-like area measuring 1 cm. Mild free fluid was noted in the periovarian region. Thickened right tube noted. Twin intra uterine sac with a fetal pole with HR of 118 bpm noted.

A repeat scan revealed (30/4/21) frontal bossing with posterior fossa cyst with a Skeletal dysplasia. Mineralization of the spine appeared poor, with the thorax appearing narrow and the abdomen appearing protuberant.

The fetal Doppler scan report revealed high risk (high resistance flow with early diastolic notch seen in both uterine arteries.)

Hence patient was admitted for termination of pregnancy. The patient was started on Tab. Misoprostol 400 mg and risks explained including D and C. After 5 doses of misoprostol, patient shifted to the observational room and Inj. Syntocin infusion was started. She expelled fetus spontaneously and the placenta removed manually on 19/5/21. Post-fetal skin and coarse tissue were sent for karyotyping which was suggestive of normal karyotyping with 46 XX chromosome complement. Post OP USG Pelvis showed thickened endometrium with area of internal vascularity- S/O residual products of conception. D C done and repeat USG reveals normal endometrium.

On 3/4/22, she presented with 2 day delay in her period and complaints of mild pain. Her UPT was positive. LMP- 3/3/22. She was started on Inj HUCOG 2000 IV weekly once for 3 days.

After 12 days, on 17/4/22, she complained of gastritis/indigestion-like pain with one episode of vomiting.

USG showed a twin live intrauterine pregnancy of 6 – 7 weeks and a complex mass lesion with an internal sac-like area in the right adnexa with a thickened right fallopian tube. MRI revealed a dichorionic diamniotic twin gestational sac with a live embryo within, a complex right adnexal mass lesion associated with mild heterotopic pregnancy (twin intrauterine pregnancy with the right tubal ectopic). Given a high likelihood of rupture, she consented for an emergency laparotomy with right salpingectomy under spinal anesthesia (18/4/22). The patient was stabilized and hence discharged on 4th POD.

A repeat scan (12/5/22) revealed fetal intra cranium, stomach, bladder, limbs to the extend seen at this period of gestation appeared normal in fetus A, structural evaluation of fetus B could not be done due to anhydramnios. DCDA twin gestation corresponding to gestational age of 12 weeks 1 day. Fetus A viable corresponds to 12 weeks. Liquor normal in the sac. Fetal movement appeared normal. Fetus B viable corresponds to 12 weeks. Anhydramnios in the sac. Fetal movement is restricted. Intertwin weight discordancy 1%.

Repeat USG (5/6/22) after one week showed diamniotic dichorionic twin live intrauterine fetuses with fetal A corresponding to 13-14 weeks with FHR of 150BPM, fetal B corresponding to 14-15 weeks with FHR of 164BPM with anhydramnios. EDD by USG 7/12/22. No obvious congenital anomalies noted at this gestational age. Patient was asked to review after 15 days.

2/3 trimester scan report (15/7/22) revealed dichorionic diamniotic (DCDA) twin gestation corresponding to 19 weeks 1-day, concordant growth. Inter twin weight discordancy 0% tile. Fetus A viable corresponds to 19-20 weeks. Liquor adequate in sac. To the extent seen no gross anomalies were detected at this period of gestation. Fetus B viable corresponds to 19-20 weeks. Liquor adequate in sac. Bilateral talipes foot and rest of the fetal structure appeared normal for the period of gestation.

2/3 trimester scan report (12/8/22) revealed DCDA twin gestation corresponding to 23 weeks 1 day. Bilateral talipes foot. Flexion and extension movements of all four limbs appeared normal. She was asked to review after 3 weeks.

0n 26/8/22 at 25+ 4 week of gestation with DCDA, she complained of leaking PV. The scan revealed normal liquor and speculum examination showed no leak and advised for observation of PV leak.

After 2 days, on 28/8/22, condition aggregated in two days with persistent small PV leaks, no pain and fetal movement normal. Patient was admitted for observation and also explained about the risks like extreme pre maturity, like ARDS, sepsis, neurological damage, long term NICU stay and IUD. Her urine routine showed pus cells 3-5/hpf, raised WBC of 10470 cells/cumm and increased neutrophils of 82%, treated for UTI. After 48 h of observation, patient had no further leaks and repeat scan for liquor volume was normal. The patient was hence discharged on medical conservative management.

4 weeks later, she presented with mild abdominal pain with blood-stained leaking PV for few hours. USG abdomen (28/10/22) showed a maximum pocket of 3cm, twin A decreased liquor, twin B with normal liquor, and normal Doppler for both twins. WBC, CRP- 5.3 was normal. Urine showed 1+ albumin, treated for UTI.

The patient had persistent blood stained (05/11/2022) PV leaking, speculum examination showed mild leak and external OS open and internal OS closed. The patient was explained about the risk pre-maturity. FH is monitored regularly. The patient was managed conservatively and was advised to go to a higher center with an NICU facility (06/11/2022)

She successfully delivered her twin male babies on 06/11/2022. Babies were managed at NICU for nearly 1 month and got discharged on 02/12/2022. Both mothers and babies are doing well.

 

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